Automaticity and habit in recognition and responses to clinical deterioration among ward nursing staff: An international cross-sectional study

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BACKGROUND: Rapid response systems aim to reduce preventable harm through early recognition and response to clinical deterioration. While most interventions target knowledge and skills, limited attention has been paid to the role of non-reflective cognitive processes, including habit and automaticity, in shaping nurses' recognition and escalation of care behaviours. OBJECTIVES: To explore automaticity in recognition and escalation of care behaviours and to examine individual and contextual factors associated with behavioural automaticity. DESIGN: International, multicentre cross-sectional survey. SETTING: Four acute hospitals in the United Kingdom (n = 2), Singapore (n = 1), and Finland (n = 1), where the National Early Warning Score 2 (NEWS2) was implemented as part of the rapid response system. PARTICIPANTS: Two hundred and twenty nursing staff working in adult acute wards including registered nurses, enrolled nurses, and healthcare assistants. METHODS: A questionnaire incorporating 22 recognition and response behaviours anchored on the Self-Report Behavioural Automaticity Index was administered. Behaviour enactment in the form of self-rated performance of each behaviour was examined descriptively and compared between countries using chi-square tests. Differences in automaticity were analysed using analysis of variance and general linear models. RESULTS: Most behaviours were widely enacted (70%-99%), although family-focused communication behaviours were reported less frequently. Mean automaticity scores ranged from 3.5 to 4.0 out of 5, indicating moderate to high automaticity. Automaticity was highest for assessing level of consciousness and recording vital signs in the health record, and lowest for asking family members how the patient appeared and speaking with family members about clinical deterioration. In general linear models, significant associations were identified for 12 of the 22 behaviours. Country was most consistently associated with automaticity, with participants from Singapore generally reporting lower automaticity than those from the United Kingdom. Job role was associated with measuring vital signs and assessing level of consciousness, with healthcare assistants reporting lower automaticity than registered nurses. Clinical area was associated with measuring respiratory rate and dialling the emergency number. Time in current role and highest nursing qualification were not significantly associated with automaticity across behaviours. CONCLUSIONS: Recognition and escalation of care behaviours are shaped not only by knowledge and protocol adherence, but also by habitual processes embedded in routine practice. Variation across behaviours and contexts suggests that implementation interventions to improve recognition and response to clinical deterioration should combine educational strategies with approaches that strengthen adaptive practice habits, while preserving reflective clinical judgement when patient presentations are complex or uncertain.

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